Link Period - 2014

1. Link Period - 2014 Documentation in the hospital: A practical guide Admission Histories and Case Presentations Admission Orders Progress Notes Discharge Summaries Dr Krista Wooller

2. Objectives UGME objectives: 10364: Write a case history on the assigned patient including diagnostic impression, problem list and approach to plan of care 10370: Demonstrate the ability to perform a written and verbal presentation on a complete history and physical examination on an assigned patient 10380: Explain the basic principles of confidentiality and documentation in the medical records 10397: Demonstrate the ability to write progress notes [Unit name – Lecture title – Prof name]

3. First half: case histories and admission orders • Second half: progress notes and discharge summaries [Unit name – Lecture title – Prof name]

4. Has anyone admitted a patient to a hospital? • Has anyone written admission orders? [Unit name – Lecture title – Prof name]

5. What happens when a patient is admitted to hospital? Decision made that patient needs to be admitted to hospital Patient in ER or clinic History and Physical exam done “Request for admission” submitted Medical student! Practice during patient centered activities! Management plan created and documented at end of history and physical Admission orders written which facilitate management plan Medical student with help from resident or attending! Medical student! [Unit name – Lecture title – Prof name]

6. Written Case History • Use standardized format (see example in Bates) • Identification • Chief complaint or reason for referral • History of presenting illness • Past medical history, past surgical history • Medications • Allergies • Social History/Functional inquiry • Family History • ROS • Physical exam findings • Laboratory and imaging findings • Impression, differential diagnosis and plan Do not omit any of these…even if your attending physician is not interested in discussing some aspect of the history. All parts are important and will be important to document when a patient comes into hospital. [Unit name – Lecture title – Prof name]

7. Written Case History • Make write-up as complete as possible • Your note should show your clinical reasoning and should support your orders • May need to adjust depending on attending [Unit name – Lecture title – Prof name]

8. Urea Na K Cr Cl HCO3 Glucose WBC Hb Plts Written Case History • Some standard shorthand: • Electrolytes: • Complete blood count: [Unit name – Lecture title – Prof name]

9. Written Case History: Impression and Plan • Most important and most difficult part of note for students • Need to integrate all the information from the history, physical and investigations • Need to show medical reasoning • Suggest making diagnosis list/problem list and discussing plan for each • Start with most important diagnosis/problem first • Some problems may need a differential diagnosis • Some will already have a diagnosis and will just need a plan [Unit name – Lecture title – Prof name]

10. Written Case History : Impression and Plan • Eg: • “ This is a 89 year old woman admitted with a femoral neck fracture after suffering a sudden syncopal attack. She has a systolic murmur on cardiac exam suspicious for valvular heart disease. • Her issues are: • 1) femoral neck fracture - she requires surgical fixation and we will ensure she is NPO in preparation for the OR. Anaesthesia to see prior. Pain control with morphine and acetominophen. Will need DVT prophylaxis. • 2) Syncope: sudden nature of the syncope is concerning for a cardiac event (arrythmia versus valvular heart disease such as aortic stenosis). Other possibilites include vaso-vagal syncope or a neurologic event. We will ask cardiology to assess urgently in order to guide further investigations and advise on safety to proceed to surgery. She will remain on telemetry until they assess her. [Unit name – Lecture title – Prof name]

11. Your turn: • Read the admission note I have given you. • Try to generate an impression and plan • what is the main problem? • what is ddx? • what is diagnostic and management plan • are there any other issues? • Don’t worry about specifics (this is what you will learn in clerkship). The idea is to get used to the format. [Unit name – Lecture title – Prof name]

12. Impression/plan : • 53 year old man with a prolonged episode of chest pain concerning for unstable angina (brought on by activity, retrosternal location, relieved with NTG and patient has risk factors for CAD including hypertension and smoking). • The differential diagnosis includes: • aortic dissection but I believe this less likely given his normal vital signs and normal peripheral pulses • GERD/PUD but less likely given the history (no relation to food) • MSK pain is possible given he was exerting himself at the time however, given his risk factors, cardiac disease would have to be exluded first before making this diagnosis. • pulmonary embolism - the pain was atypical of a pulmonary embolism and he has no risk factors. • Plan: He will be admitted for observations, send cardiac biomarkers, ECG and CXR now. He will likely need either non-invasive stress testing or angiography based on results. I will start ASA and prn NTG spray now while awaiting results of tests. He should be maintained on a cardiac monitor until diagnosis clear. [Unit name – Lecture title – Prof name]

13. Other problems to add to problem list? [Unit name – Lecture title – Prof name]

14. smoking • alcohol use [Unit name – Lecture title – Prof name]

15. Verbal Case Presentation [Unit name – Lecture title – Prof name]

16. Verbal Case Presentations • There is an art to the case presentation • Difficult skill for medical students to master * one of the most important skills you can learn in your training* [Unit name – Lecture title – Prof name]

17. Verbal Case presentation • Start with introduction • Who the patient is and why they need our attention today • Eg 88 year old man from nursing home referred with dyspnea • Eg 3 year old girl and her parents presenting with constipation • Eg 24 year old university student referred for assessment of possible anxiety disorder [Unit name – Lecture title – Prof name]

18. HPI – tell story chronologically • E.g. “patient was well until 4 days ago when she noticed swelling and discomfort of left leg” • Give all pertinent positives and negatives in HPI to fully describe the patients symptoms • E.g.. “ there was associated fever and chills for last 24 hours, no associated trauma or injury to the leg, noted erythema over the posterior calf which spread to the whole lower leg and foot yesterday. The patient has no risk factors for DVT (no malignancy, no immobilization, no pmh of VTE, no family history of VTE) [Unit name – Lecture title – Prof name]

19. Present rest of history • Past medical history, past surgical history • Medications • Allergies (if relevant to case) • Social history and functional inquiry (more or less detailed depending on relevance to case) • Family history (only if relevant) [Unit name – Lecture title – Prof name]

20. ROS • Usually don’t verbally present ROS – this is a way for you to ensure you didn’t miss anything. Anything uncovered in ROS which is relevant should be discussed in the HPI or PMH. [Unit name – Lecture title – Prof name]

21. Pause, then present physical exam • “On exam…” [Unit name – Lecture title – Prof name]

22. Only present pertinent positives and negatives in physical exam • Always state general appearance • Always state vital signs • Document complete findings in write up, but be more concise in verbal presentation • If main complaint is abdominal pain then will need to verbally present whole abdomen exam including findings such as Murphy’s sign, etc • If main complaint is ear pain, then stating that abdomen exam normal is likely sufficient • Preceptor can always ask for more details if needed. [Unit name – Lecture title – Prof name]

23. How do you know what is pertinent? • Relates to differential diagnosis • Eg If complaint is dyspnea, pertinent findings are all the features on history, physical and investigations that help narrow the differential diagnosis • fever, cough , sputum, inspiratory crackles, elevated wbc, infiltrate on CXR– community acquired pneumonia • PND, orthopnea, ankle edema, JVP, PMI, S3, S4, pulmonary edema on CXR – CHF • Weight loss, night sweats, endemic area or TB exposure – TB • Weight loss, smoking history, lymphadenopathy, mass on CXR - cancer [Unit name – Lecture title – Prof name]

24. Present yourfindings – don’t present conclusions • E.g. left leg was warm to touch and erythematous to knee. Diameter of leg 10 cm below tibial tuberosity was equal to right leg. No open wounds…..etc • Do not say “ patient had cellulitis of left leg” (this is a conclusion you make after considering the history, physical exam, and investigations) [Unit name – Lecture title – Prof name]

25. Listener knows you are a third year medical student – state your findings clearly and don’t hedge every statement with disclaimers about your level of training! • If you want a physical exam finding checked – ask when you are done the presentation [Unit name – Lecture title – Prof name]

26. Investigations • Present pertinent positive and negatives only • Lab work, ECG, imaging, culture results, etc [Unit name – Lecture title – Prof name]

27. Your turn… • Return to the case history • Pick out what you think is a pertinent positive to present from the physical exam in and circle it with your group • Pick out what you think is a pertinent negative to present from the physical exam and underline it [Unit name – Lecture title – Prof name]

28. Pertinent positives: • not many as physical exam normal! Pain score? • Pertinent negatives: • many as relevant for ddx and complications for ?unstable angina • vital signs • cardiac exam (pulses, bruits, aorta, murmur, rub, heart sounds, JVP, edema ) • resp exam • GI exam [Unit name – Lecture title – Prof name]

29. Impression: • Impression and plan: • Aim for one sentence summary of case • Present presumed diagnosis or differential diagnosis • Present diagnostic and management plan [Unit name – Lecture title – Prof name]

30. Your impression and plan should be supported by the preceding information. • Your clinical reasoning should be clear to those reading your note or those listening to the case presentation Eg. Impression and Plan: • “In summary, this is a 66 year old woman with a 3 day history of erythema, swelling and pain of left calf. Given her fever and elevated white cell count the most likely diagnosis is cellulitis although a deep vein thrombosis is also in the differential. My plan is to draw blood cultures and initiate antibiotics (cefazolin). I will also do an ultrasound of the leg to rule out a DVT. She needs to be admitted to hospital to receive iv antibiotics until she shows improvement” [Unit name – Lecture title – Prof name]

31. Friday tutorial after patient centered activities will be chance to listen to case presentations and give a case presentation [Unit name – Lecture title – Prof name]

32. Discussion/Questions? Dr Wooller’s Top 10 tips for good case histories and verbal presentations: • 1) Be polished and confident when presenting - okay to use notes but aim to be able to present without them • 2) Never make up findings • 3) The HPI is crucial...tell the story of the patient and why they need assessment today • 4) Use structured format and don’t deviate from it unless instructed by listener • 5) Thoroughly document case history/physical...sometimes you don’t realize what is important • 6) Know your audience • 7) Make sure your clinical reasoning is evident • 8) Discuss issues in order of importance • 9) Practice, practice, practice • 10) Ask for feedback [Unit name – Lecture title – Prof name]

33. [Unit name – Lecture title – Prof name]

34. How to Write Admission Orders

35. Specifically, by the end of the session: Recall a mnemonic for admission orders Identify resources for safe and unsafe abbreviations List the elements of good order writing Write 2 sets of practice orders Objectives [Unit name – Lecture title – Prof name]

36. What is an “order”? What are admission orders? Question: [Unit name – Lecture title – Prof name]

37. What happens when a patient is admitted to hospital? Decision made that patient needs to be admitted to hospital Patient in ER or clinic History and Physical exam done “Request for admission” submitted Medical student! Management plan created and documented at end of history and physical Admission orders written which facilitate management plan Medical student with help from resident or attending! Medical student! [Unit name – Lecture title – Prof name]

38. Admission orders • Set of instructions to guide the care of a patient when in hospital • Nothing happens unless it is in the orders • Physicians write most orders and must co-sign most orders written by other health care professionals • “MRP”= most responsible physician. Must approve all orders for patient under their care. • You will write orders but have them co-signed by a physician while you are still a medical student. [Unit name – Lecture title – Prof name]

39. Daily orders • the admitting orders remain active for the duration of the patient’s stay in hospital unless a new order is written • Eg stop a medication, change patient diet, etc [Unit name – Lecture title – Prof name]

40. Memory aid to remember everything that needs to be in admission orders: ADD – DAVID ADD – DAVI4D [Unit name – Lecture title – Prof name]

41. A = Admit to (service, attending physician) Eg: “Admit to general surgery team B with Dr Chadwick” D =Diagnosis Eg: “Diagnosis: Cholecystitis” D=“DNR status” (End-of-life treatment plan if discussed with patient) [Unit name – Lecture title – Prof name]

42. D= Diet Eg. DAT = diet as tolerated, renal diet (low K and low Na), heart healthy (low sodium, low fat), diabetic diet, NPO = nothing by mouth A = Activity Eg. AAT=activity as tolerated, bedrest, fall risk V= Vitals (q 8 hours, q4h, etc.) [Unit name – Lecture title – Prof name]

43. I =Instructions to nurse Eg. daily weights, capillary blood sugar monitoring, monitoring urine output, etc I =I.V. orders Eg. I.V saline lock (ensures patient has iv in place, but nothing running through it), IV TKVO = “to keep vein open” basically very low rate to keep iv patent (10-20 ml/hour), or iv rate with iv fluid type I = Investigations Eg. bloodwork, radiology, EKGs, consultations I =Isolation status Eg. airborne, contact, droplet, etc [Unit name – Lecture title – Prof name]

44. D= Drugs All the medications the patient needs - Home meds you want to continue - New medications you want to prescribe - prn (=as needed) medications the patient may need - Don’t forget O2 - Should consider DVT prophylaxis if indicated [Unit name – Lecture title – Prof name]

45. Orders must be . . . [Unit name – Lecture title – Prof name]

46. …signed • Date, time, signature and printed name, with “rank” (MS3,MS4, R1 etc) • Use 24 hour clock for orders • August 30, 2010 14:00. K. Wooller MS 3, • Remember that all your orders need a co-sign before your patient can get any care *it is your responsibility to get orders co-signed* [Unit name – Lecture title – Prof name]

47. …have accompanying paperwork • Fill out requisitions for all investigations (or enter on CPOE) • Fill out consultation requests for all consultations • CALL physician-to-physician consultations in the hospital yourself! [Unit name – Lecture title – Prof name]

48. …clearly explain medications One line per medication Always include: generic drug name, dose, route, frequency and timing PRN medications should include the parameters for when to give medication If uncertain: check with a reference, resident, staff or speak to a pharmacist [Unit name – Lecture title – Prof name]

49. …be legible handwriting abbreviations * remember – if people can’t read or understand what you have written then it will not happen* (Computerized order entry will help) [Unit name – Lecture title – Prof name]

50. [Unit name – Lecture title – Prof name]